Improving Quality of Care and Patient Outcomes with Evidence-based Practice and the ARCC Model Bernadette Mazurek Melnyk, PhD, CPNP/PMHNP, FNAP, FAAN Associate Vice President for Health Promotion, University Chief Wellness Officer, Dean, College of Nursing Associate Editor, Worldviews on Evidence-Based Nursing
In God We Trust, Everyone Else Must Bring Data!
The State of Healthcare There are up to 200,000 unintended patient deaths per year (more than auto accidents & breast cancer) Patient injuries happen to approximately 15 million individuals per year Only 5% of medical errors are caused by incompetence where 95% of errors involve competent persons trying to achieve right outcomes in poorly designed systems with poor uniformity Patients only receive about 55% of the care that they should when entering the healthcare system
The Cost of Poor Quality Healthcare Poor quality healthcare cost the United States about 720 billion dollars in 2008 Wasteful healthcare spending costs the healthcare system 1.2 trillion dollars annually The U.S. healthcare system could reduce its healthcare spending by 30% if patients receive evidence-based healthcare -RAND
Kaylin s Story: Australian Dream Trip Turned Nightmare From Melnyk, B.M., & Fineout-Overholt, E. (2011). Implementing EBP: Real World Success Stories
The U.S. Navy Blue Angels A High Reliability Organization Requires intense focus, leadership, outstanding communication, teamwork, data based practices, root cause analysis of errors, a safety and continuous learning culture, improvement processes and outcomes evaluation http://www.youtube.com/v/ekctdca9yts
A High Reliability Healthcare Organization A high reliability healthcare organization provides care that is safe and one that minimizes errors while achieving exceptional performance in quality and safety A healthcare organization that has measurable near perfect performance on quality of care, patient safety and efficiency Creating a culture and processes that radically reduce system failures and effectively respond when failures do occur is the goal of high reliability thinking
A Culture of Patient Safety Essential Components (Sammer et al., 2010) Leadership Teamwork Evidence-based Communication Learning Just Patient-centered
Stay Tuned for the Nurse Athlete A Key Strategy for Enhancing Engagement, Reducing Stress, Fatigue and Burnout
What is Evidence? A collection of facts that grounds one s belief that something is true (Dictionary.com 2007) External versus internal evidence - External evidence: generated from rigorous research - Internal evidence: generated from outcomes management; practice based evidence Does the evidence that is generated through rigorous research still hold when translated to the real world?
The So What Factor in an Era of Healthcare Reform Conducting research and EBP projects with high impact potential to positively change healthcare systems, reduce costs and improve outcomes for patients and their families Key questions when embarking on a research study or an EBP project: So what will be the end outcome of the study or EBP project once it is completed? So what difference will the study or EBP project make in improving healthcare quality, costs or patient outcomes?
Evidence-Based Practice Evidence-based practice (EBP) is a problem solving approach to clinical practice that integrates the conscientious use of best evidence in combination with a clinician s expertise as well as patient preferences and values to make decisions about the type of care that is provided. Resources must be considered in the decision-making process as well.
The Merging of Science and Art: EBP within a Context of Caring & EBP Culture Results in the Highest Quality of Patient Care Context of Caring EBP Culture Research Evidence & Evidence-based Theories Clinical Expertise and Evidence from assessment of the patient s history and condition as well as healthcare resources Clinical Decisionmaking Quality Patient Outcomes Patient Preferences and Values Melnyk & Fineout-Overholt, 2003
Acting on the Evidence Strength of the Evidence + Quality of the Evidence = Confidence to Act!
The IOM Roundtable on EBM Formed in response to the 2003 IOM s Committee on the Health Professions Education Summit recommendation that All healthcare professionals will be educated to deliver patient-centric care as members of an inter-disciplinary team, emphasizing EBP, quality improvement approaches and informatics Ninety percent of healthcare decisions will be evidence-based by 2020 - The IOM Roundtable on EBP
Annual Guide to Clinical Preventive Services Evidence-based gold standard recommendations adapted for a pocket-sized book Formatted for clinicians to consult for clinical guidance in their daily practice Recommendations are presented in an indexed, easy-to-use format with ata-glance charts
Why Must We Accelerate Evidence-Based Practice in Healthcare Providers and Systems Across the U.S?
Patient Outcomes With and Without Evidence-Based Practice
Why Must We Accelerate EBP? Despite an aggressive research movement, the majority of findings from research often are not integrated into practice It takes approximately 17 years to translate research findings into practice It is estimated that only approximately 10-15% of clinicians in the U.S. are consistently implementing EBP
COPE (Creating Opportunities for Parent Empowerment): An Evidence-Based Program to Improve Outcomes in Critically Ill/Hospitalized Young Children, LBW Premature Infants & Parents
The COPE NICU Program
A 4 Day Shorter Length of Stay (LOS) for COPE Preterms Resulted in Cost Savings of $5000 per infant; 8 Day Shorter LOS for Preterms < 32 Weeks 40 35 30 25 20 15 10 5 0 32.9* NICU LOS 35.7 35.6* * *p <.05 39.6 NICU + Transfer Hospital LOS COPE Comparison
Cost Analysis The net direct health care cost savings per child through NICU discharge after deducting the cost of the COPE intervention was $4,864 Further subgroup analyses for LOS based on birthweight revealed that COPE infants <1500 grams had an even shorter NICU length of stay (n = 90, 8.3 days), which resulted in even greater savings
The Current RCT with COPE Funded by NIH/NINR R01#NR012171 Purpose: to determine the efficacy of the 15-session COPE Healthy Lifestyles TEEN (Thinking, Emotions, Exercise, Nutrition) Program on the healthy lifestyle beliefs, behaviors and mental health of 800 teens in Phoenix Area High Schools
Why Must We Accelerate EBP? A high JASPA score (Journal of Associated Score of Personal Angst) J: Are you ambivalent about renewing your Journal subscriptions? A: Do you feel Anger toward prolific authors? S: Do you ever use journals to help you Sleep? P: Are you surrounded by piles of Periodicals? A: Do you feel Anxious when your journals arrive? Modified from BMJ (1995), 311, 166-1668
Why Must We Accelerate EBP? Practices routed in tradition are often outdated and do not lead to the best patient outcomes. Daily changing of IV dressings Perineal shaves before child birth Mayonnaise for head lice Sugar paste for pressure ulcers Albuterol delivery with nebulizers
The Steps of EBP Step 0: Cultivate a Spirit of Inquiry & EBP Culture Step 1: Ask the PICO(T) Question Step 2: Search for the Best Evidence Step 3: Critically Appraise the Evidence Step 4: Integrate the Evidence with Your Clinical Expertise and Patient Preferences to Make the Best Clinical Decision Step 5: Evaluate the Outcome(s) of the EBP Practice Change Step 6: Disseminate the Outcome(s)
The EBP Process Ignite the Spirit of Inquiry Formulate a Searchable, Answerable PICO Question Streamlined, Focused Search Rapid Critical Appraisal & Synthesis of Evidence Apply Valid, Relevant Evidence Generate Evidence Internal: OM, QI External: Research Evaluate the Outcome(s) and Disseminate the Findings Melnyk, Fineout-Overholt, Stillwell, 2009
A Critical Step in EBP: The PICO(T) Question Ask the burning clinical question in PICO(T) format Patient population Intervention or Interest area Comparison intervention or group Outcome Time In premature infants (P), how does music (I) versus massage (C) affect oxygen saturation (O) while in the NICU (T)?
Levels of Evidence Usefulness for Cause & Effect Decision Making Systematic review or metaanalysis of all relevant randomized controlled trials (RCTs), Evidence-based clinical practice guidelines based on systematic reviews of RCTs Evidence obtained from at least one well-designed RCT Evidence obtained from welldesigned controlled trials without randomization and from well-designed case-control and cohort studies Evidence from systematic reviews of descriptive and qualitative studies Evidence from a single descriptive or qualitative study Evidence from the opinion of authorities and/or reports of expert committees
Levels of Chocolate Godiva Truffles Donnelly Chocolates Decadence Ghirardelli Chocolate Bars Hershey Kisses Fannie Farmer Sampler Nestle s Quik Inspirational quotes are fine, but you ll motivate more people with chocolate. Modified from Julia Sollenberger, University of Rochester
Why Measure the Outcomes of EBP? Outcomes reflect IMPACT! EBP s effect on patients Physiologic (complication reduction; health improvement) Psychosocial (quality of life; depressive and anxiety symptoms; patient satisfaction with care) Functional improvement EBP s effect on the health system Decreased cost, length of stay Nursing retention / job satisfaction Interdisciplinary collaboration
Major Barriers to the Advancement of EBP Lack of knowledge and skills Low comfort level with search techniques Perceived lack of time Challenges with critically appraising research Lack of organizational/administrative support Educational programs that continue to teach research the traditional way with a focus on producing instead of using evidence Negative attitudes toward research
Colleagues who are skeptical of or who do not believe in EBP
Evidence-Based Facilitators of EBP Individual knowledge and skills of EBP Beliefs that EBP improves care and outcomes Beliefs in the ability to implement EBP Mentors who are skilled in EBP Administrative/organizational support, including executives/managers that model and encourage EBP
Facilitators Champions, I Evidence mentors and nurse executives/manager s who are passionate about EBP
q for a Successful Change to System-wide EBP A Vision with Specific Written Goals We must begin with the end in mind
Ask yourself: What would you do if you knew you could not fail in the next 2 to 3 years? What is the smallest EBP change that you can make tomorrow that positive outcomes? would have the largest impact for your patients
SHOCK! You are asking me to implement EBP on top of everything else that I do?
Stressed!
Change Fatigue
The Change Curve Model by Jeanie D. Duck Knowing what to expect as part of the change process will enhance success!!!
Melnyk & Fineout-Overholt s ARCC Model
Evidence to Support ARCC Study #1: Descriptive correlational study with 160 nurses Study #2: A psychometric study of the EBP beliefs and EBP implementation scales with 360 nurses Study #3: A randomized controlled pilot study with 47 nurses in the VNS Study #4: A quasi-experimental study with 159 nurses in a clinical research medical center environment Study #5: A pre-experimental study with 52 clinicians at WHHS
Outcomes of Implementing the ARCC Model at Washington Hospital Healthcare System Early ambulation in the ICU resulted in a reduction in ventilator days from 11.6 to 8.9 days and no VAP Pressure ulcer rates were reduced from 6.07% to.62% on a medical-surgical unit Education of CHF patients led to a 14.7% reduction in hospital readmissions 75% of parents perceived the overall quality of care as excellent after implementation of family centered care compared to 22.2% pre-implementation
Creating a Culture to Implement and Sustain EBP: What Works
The only person that likes a change is a baby with a wet diaper!
Critical Components of an EBP Culture A philosophy, mission and commitment to EBP: there must be organizational commitment to advance EBP A Spirit of Inquiry: all health professionals are encouraged to question their current practices A Cadre of EBP Mentors: who have in depth knowledge and skills in EBP, mentoring others, and overcoming barriers to individual and organizational change
Critical Components of an EBP Culture Administrative Role Modeling and Support: leaders who value and model EBP as well as provide the needed resources to sustain it Infrastructure: tools and resources that enhance EBP across the organization, such as computers for searching and up to date data bases Recognition: individuals and units are rewarded regularly for EBP
Diffusion of Innovation Early Majority 34% Late Majority 34% Laggards 16% Innovators 2.5% Early Adopters 13.5% Culture shift Culture shift
A key ingredient for success is persistence as there will be many character-building experiences along the way!! At least I have found 9000 ways that it won t work." Thomas Edison
Persistence is a Key to Success Theodor S. Geisel wrote a children s book that was rejected by 23 publishers. The 24 th publisher sold 6 million copies of the first Dr. Seuss Book.
Worldviews on Evidence-Based Nursing Linking Evidence to Action Editor: Jo Rycroft-Malone, RN, PhD Associate Editors: Tracey Bucknall, RN, PhD Bernadette Mazurek Melnyk, PhD, CPNP, PMHNP, FAAN Impact Factor 1.94 New: Ranked 1 st in the ISI Citation Report (2010) Gives readers methods to apply best evidence to practice Global coverage of practice, policy, education and management From a source you can trust, the Honor Society of Nursing, Sigma Theta Tau International Time to submit Time to subscribe: www.blackwellpublishing.com/wvn
American Journal of Nursing Evidence-Based Practice, Step by Step: 10-part series Articles appeared every other month Periodic "Ask the Authors" call-ins See www.ajnonline.com.
????? because we ve?? always done it that way.? Anonymous??
Nothing Happens Unless First a Dream! Carl Sandburg
Skeptics say that will happen when pigs fly Research & EBP Innovators say Pigs can fly!
The Next 2-3 Years What would you do tomorrow and in the next 2 to 3 years if you know that you could not fail? Shoot for the moon, even if you miss, you will hit the stars -Les Brown There Is A Magic In Thinking Big!
Contact Information Bernadette Mazurek Melnyk 614-292 292-4844 melnyk.15@osu.edu